=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760707517
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. LAURA JANE SHEPHERD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2010
-----------------------------------------------------
Last Update Date | 04/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 COLOMA ST
-----------------------------------------------------
City | PLACERVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95667-4408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-306-7412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 COLOMA ST
-----------------------------------------------------
City | PLACERVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95667-4408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-306-7412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | RI-S0903301558
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------